Introduction: Despite advancements in biologic therapy, obtaining complete remission in patients with severe stricturing Crohn’s Disease can be quite challenging. Our case highlights an unfortunate patient with severe medical-refractory Crohn’s disease who ultimately achieved clinical remission using dual immunomodulator and biologic therapy with tofacitinib and vedolizumab.
Case Description/Methods: We present a 62-year-old male with a long history of ileocolonic Crohn’s disease. He was initially diagnosed in 2011 after presenting with abdominal pain. Colonoscopy at diagnosis noted ileocolonic inflammation with supportive biopsies of IBD. He was started on infliximab with improvement however this was discontinued due to financial hardships. He was transitioned to combination therapy with adalimumab and methotrexate in 2014 however his disease progressed, resulting in an SBO in 2017 requiring an ileocecectomy. He was then started on ustekinumab in 2018. Unfortunately restaging at six months noted active disease at his anastomosis. He was transitioned then to vedolizumab in 2019, however one year later was noted to have persistent inflammation at the anastomosis with stricture refractory to corticosteroids. He underwent further resection with diverting ostomy with eventual takedown in 2020 after multiple hospitalizations for high ostomy output. He was quickly restarted on vedolizumab with aggressive therapeutic drug monitoring with evidence of persistent disease activity despite the addition of methotrexate. Following a multidisciplinary discussion, his methotrexate was exchanged for tofacitinib in early 2022 with drastic improvement in both symptoms and biomarkers. Aside from a brief self-limited episode of norovirus gastroenteritis, he has tolerated dual therapy well with few adverse events. He is undergoing restaging this summer.
Discussion: This case highlights the efficacy of using dual biologic and immunomodulator therapy to help treat a patient with refractory Crohn’s Disease. It is well established that combining biologics and immunomodulators can help wean steroid dependence and maintain remission in patients who suffer from IBD. While several studies have evaluated the use of tofacitinib and vedolizumab in Ulcerative Colitis, few studies have looked at rates of remission in Crohn’s Disease. This case demonstrates that the use of off-label dual biologic and immunomodulator therapy for treatment of refractory Crohn’s disease can be an effective and safe treatment for this cohort of patients.
